Doi:10.1016/j.annemergmed.2005.07.00

Nonprescription Availability of Emergency Contraception
in the United States: Current Status, Controversies, and
From the Department of Emergency Medicine, Brown Medical School, Providence, RI.
In October 2004, the American College of Emergency Physicians Council joined more than 60 otherhealth professional organizations in supporting the nonprescription availability of emergencycontraception. This article reviews the history, efficacy, and safety of emergency contraception; theefforts toward making emergency contraception available without a prescription in the United States;the arguments for and against nonprescription availability of emergency contraception; and thepotential impact nonprescription availability could have on the practice of emergency medicine in theUnited States. [Ann Emerg Med. 2006;47:461-471.]
0196-0644/$-see front matterCopyright ª 2006 by the American College of Emergency Physicians.doi:10.1016/j.annemergmed.2005.07.001
efficacy of emergency contraception using a lower-dose
At the 2004 American College of Emergency Physicians
combination of estrogen and progestin. Thereafter, the ‘‘Yuzpe
(ACEP) Scientific Assembly in San Francisco, CA, the ACEP
method’’ became the standard for emergency contracep
Council passed a member-sponsored resolution stating that
The Yuzpe emergency contraception method includes 200 mg of
ACEP ‘‘supports the availability of nonprescription emergency
ethinyl estradiol and either 1.0 mg of levonorgestrel or 2.0 mg
contracepBy passing this resolution, ACEP joins other
of norgestrel in 2 divided doses 12 hours apart. The first dose is
health professional organizations, including the American
taken within 72 hours of unprotected intercourse. The Yuzpe
Medical Association, the American Public Health Association,
method can be used with most commonly available oral
the American College of Obstetricians and Gynecologists, the
contraceptive pills (eg, Ovral [ethinyl estradiol/norgestrel], Alesse
American Academy of Pediatrics, and at least 60 other
[ethinyl estradiol/levonorgestrel]).
organizations in advocating for the release of restrictions on
The Yuzpe method has been shown in several studies to be
selling birth control pills for emergency contraception over-the-
effective. For example, in 1977 Yuzpe and Lancee observed the
counter in the United States.The resolution primarily serves
occurrence of only 1 pregnancy among 608 women taking
to clarify ACEP’s position on this matter. To elucidate the
200 mg of ethinyl estradiol and 2.0 mg of norgestrel after
reasons behind this resolution, this article will review the
unprotected intercourse.In a 1982 study, Yuzpe et al
history, efficacy, and safety of emergency contraception; the
observed an 84% reduction in the estimated risk of pregnancy
efforts toward making emergency contraception over-the-
among women using emergency contraception. Other
counter in the United States; the arguments for and against
researchers have found even greater reductions of pregnancy risk
over-the-counter emergency contraception; and the potential
impact over-the-counter emergency contraception could have
Many alternatives to the Yuzpe method for emergency
on the practice of emergency medicine in the United States.
contraception exist and have been evaluated for effectiveness inpreventing pregnancy. Levonorgestrel alone, a progestin-only
version of emergency contraception, has been extensively
researched and is a widely used alternative to the Yuzpe
Apart from intrauterine devices that are infrequently inserted
method.In a double-blind, multicenter, randomized,
as a postcoital preventive measure, emergency contraception
controlled trial of 1955 women, the World Health Organization
primarily consists of the use of oral contraceptive pills after sexual
(WHO) found a levonorgestrel-only emergency contraception
intercourse to prevent pregnancy. Emergency contraception
regimen to be more effective in preventing pregnancy than the
using high-dose estrogens was first reported in 1964 in the
Yuzpe method.According to a Cochrane review, the relative risk
NetherlanIn 1974, Yuzpe et aldemonstrated the safety and
of pregnancy with a levonorgestrel-only regimen versus the Yuzpe
Nonprescription Availability of Emergency Contraception in the United States
method is 0.51 (95% confidence interval 0.31 to 0.83).The
effectiveness of the Yuzpe method if taken between 72 and
same review concluded that taking both levonorgestrel pills as a
120 hours after unprotected intercourse; they reported a
single dose is clinically equivalent to the 2-dose regimen. In
reduction in pregnancy risk of 87% to 90% if taken fewer
addition, in a double-blind, multicenter, randomized, controlled
than 72 hours versus 72% to 87% if taken between 72 and
trial, a norethindrone-based emergency contraception regimen
120 hours. Ellertson et similarly observed that the estimated
was as effective in preventing pregnancy as a standard 2-dose
reduction in pregnancy for the Yuzpe method 96 to 120 hours
after unprotected sexual intercourse was 77.2% with perfect
Non–estrogen-based emergency contraception options exist
compliance and was 54.6% with typical compliance.
that might be more effective and perhaps work as emergency
The commonly reported adverse effects of the Yuzpe regimen
contraception and perhaps work by different mechanisms. The
include nausea (50.5%), vomiting (18.8%), dizziness (16.7%),
antiprogestin mifepristone (RU-486) can be used for emergency
fatigue (28.5%), headache (20.2%), and lower abdominal pain
contraception in much smaller doses than are necessary to induce
(20.9%Adverse effects reported with levonorgestrel-only
abortion. A Cochrane summary of 7 trials comparing low-dose
regimens are significantly less frequent: nausea (23.1%),
(\10 mg) mifepristone to levonorgestrel and 3 trials comparing
vomiting (5.6%), dizziness (11.2%), fatigue (16.9%), headache
low-dose mifepristone to the Yuzpe regimen reported that the
(16.8%), and lower abdominal pain (17.6%). Nausea and
effectiveness of mifepristone is at least as good as, and may be
vomiting can be mitigated by administering antiemetics 1 hour
better than, either of these methods.Unlike other hormonal
before or by taking emergency contraception with food.
methods (discussed below), the increased efficacy of mifepristone
However, a recent study disputed the nausea-mitigating effect of
is attributed to its ability to inhibit implantation, as well as
food.Menstrual spotting is observed occasionally, and early
ovulatiDanazol (an antigonadotropin) has also been
compared to the Yuzpe method, but data are insufficient to
Two major adverse effects, ectopic pregnancy and
conclude differences in effectiveness.
thromboembolism, have been hypothesized to be associated with
Emergency contraception’s mechanism of action is not
emergency contraception usage. Ectopic pregnancy has been
known definitively. The Yuzpe method most likely prevents
noted in 4 patients who used the Yuzpe regimenand in 19
pregnancy by inhibiting or delaying ovulation.It may also
patients who used the levonorgestrel-only regimenAccording
interfere with corpus luteum formation or implantation,
to a Cochrane review, however, only 5 ectopic pregnancies have
modulate luteinizing hormone levels, and perhaps inhibit
been reported among a group of 33,110 women using emergency
transport of sperm, egg, or embryo in the fallopian tubes. There
contraception.In postmarketing surveillance studies of
is no evidence that the Yuzpe method directly interferes with
levonorgestrel, among 4.4 million units of levonorgestrel sold,
fertilization. Levonorgestrel probably prevents pregnancy by
only 8 cases of ectopic pregnancies were reported.The incidence
blocking or delaying ovulation.The precise mechanism
of ectopic pregnancies is lower than that expected based on the
of emergency contraception likely depends on when in the
observed failure rate for emergency contraception. In other words,
menstrual cycle emergency contraception is taken.Some
given the number of pregnancies expected to occur because of
studies suggest that emergency contraception is not effective
emergency contraception failure, 700 ectopic pregnancies would
once fertilization has occurred,whereas others dispute this
be predicted among the group studied. Thromboembolic events,
assertion.With the possible exception of mifepristone,
including retinal vein thrombosisand cerebrovascular
given that emergency contraception’s mechanism of action is
infahave been described in 3 case reports in patients
certainly before implantation and is likely before fertilization,
using the Yuzpe method. However, Vasilakis et reviewed the
most authorities, including the United States Food and Drug
cases in the General Practice Research Database of the United
Administration (FDA) and the WHO, do not consider
Kingdom of 73,302 women who were younger than 50 years and
emergency contraception an abortifacienEmergency
received emergency contraception between 1989 and 1996 and
contraception has no effect on established pregnancies (ie, those
found no cases with idiopathic deep venous thrombosis or
already implanted in the endometrium), because administration
pulmonary embolism. The current standard of care in the United
of hormones alone will neither interrupt nor adversely affect
States, nonetheless, is use of a progestin-only emergency
contraception formulation for women at risk of venous
Because emergency contraception probably exerts its effect
thromboembolism under the reasoning that if thromboembolism
before fertilization, pregnancy is prevented more effectively the
were a true adverse effect of emergency contraception, it would
earlier emergency contraception is administered. Effectiveness
presumably be due to the estrogen in some emergency
varies, depending on the regimen used, compliance with dosing
schedules, and time elapsed since sexual intercourse, as well as
In recognition of the possible adverse effects associated with
individual variations in menstrual cycles.The WHO found
emergency contraception, the WHO concludes that there are no
that the greatest effectiveness of both the levonorgestrel and
absolute medical contraindications for emergency contraception
Yuzpe regimens occurred when emergency contraception was
with Yuzpe or levonorgestrel-only regimens.They do
taken fewer than 24 hours after unprotected intercourse.
advise that patients with a history of severe cardiovascular
Rodrigues et observed continued, albeit decreased,
complications, angina pectoris, migraines, or severe liver disease
Nonprescription Availability of Emergency Contraception in the United States
require careful follow-up when taking emergency contraception.
distribute emergency contraception as part of a collaborative
Pregnancy is considered a contraindication only because emergency
practice agreement with an authorized prescriber. The
contraception is not effective once a woman is already pregnant.
obligation to find a willing collaborator (a physician or midlevel
The WHO does not consider emergency contraception usage
practitioner, depending on the state) falls on the pharmacist.
during pregnancy harmful to a woman or her fetus.
California and New Mexico permit pharmacists to dispenseemergency contraception under a statewide protocol; California
also permits collaborative practice agreements with authorized
prescribers. The number of pharmacists participating in
In 1994, the Center for Reproductive Law and Policy
these states’ programs differs widely, from approximately
petitioned the FDA to require manufacturers of combined oral
15 pharmacists in Alaska to greater than 2500 in California.
contraceptive pills to amend their labeling and patient
State population notwithstanding, this variability is thought to
packaging to include information on the use of these products
reflect differences in ease of certification for emergency
for emergency contraception.The FDA declined the petition
contraception dispensation, as well as differences in degree of
and referred the matter to their advisory committee. In 1996,
pharmacist and public interest in pharmacist-dispensed
the advisory committee unanimously concluded, and the FDA
concurred, that 4 brands of estrogen/progestin combination oral
The history of attempts to make emergency contraception
contraceptive pills are safe and effective as emergency
available over-the-counter in the United States begins in 2001,
contraception. The FDA also stated that it would accept
when the Center for Reproductive Rights submitted a ‘‘citizens’
applications for dedicated emergency contraception products
petition’’ to the FDA requesting that emergency contraception
without requiring further trials to prove safety and efficacy.
be made available over-the-counter throughout the United
Pharmaceutical companies were, however, hesitant to create
StatesThe FDA did not amend its policies based on this
dedicated emergency contraception products, citing concerns
petition. In April 2003, Women’s Capital Corporation
about liability, limited profit potential, and abortion politic
petitioned the FDA to distribute Plan B as an over-the-counter
In September 1998, the FDA approved marketing of the first
medication. In response, 2 FDA advisory groups, the
dedicated emergency contraception product, Preven (ethinyl
Nonprescription Drugs Advisory Committee and the Advisory
estradiol/levonorgestrel combination, originally produced by
Committee for Reproductive Health, held a joint meeting to
Gyne´tics, Inc, Somerville, NJ), a prepackaged version of the
consider the appropriateness of over-the-counter Plan B. In
Yuzpe regimen.In July 1999, the FDA approved marketing of
December 2003, these expert committees voted 24 to 3 to
Plan B (levonorgestrel only, originally produced by Women’s
recommend that the FDA permit Plan B over-the-counter
Capital Corporation [Washington, DC], now a subsidiary of
sales. Despite this recommendation, acting director Steven
Barr Laboratories, Pomona, NJ). Preven, later sold to Barr
Galson, of the FDA’s Center for Drug Evaluation and Research,
Laboratories, is no longer being manufactured.No further
declined the over-the-counter application in May 2004.
applications for dedicated emergency contraception products
Galson stated that Barr Laboratories had ‘‘not provided adequate
data to support a conclusion that Plan B can be used safely byyoung adolescent women for emergency contraception without
the professional supervision of a practitioner licensed by law to
administer the drug.’’ Of note, the joint committees had
At least 37 countries permit emergency contraception
discussed this issue and concluded that there was sufficient
dispensation directly from pharmIn most of these
information to deem it safe for this population. Barr Laboratories
countries, women must consult a pharmacist to receive
reapplied for over-the-counter status for Plan B for women older
emergency contraception. In Norway and Sweden, emergency
than 16 in July 2004, and the FDA agreed to reconsider this
contraception can be obtained from pharmacy shelves
revised application.Although a decision was due on January
without the assistance of a pharmacist.On April 19, 2005,
21, 2005, the FDA delayed its decision because of an ‘‘inability
Health Canada (the Canadian Ministry of Health) approved
to review’’ all available informaThe Center for
the sale of 0.75 mg of oral levonorgestrel without a prescription
Reproductive Rights has filed suit against the FDA for failing to
by pharmacists under a defined prescription algorithm. The
algorithm assures standardized assessment, counseling, anddispensation practicThe schedule change for this
medication permits the over-the-counter sale of Plan B.
Before this change, 2 provinces, Quebec and British
Those who support the over-the-counter availability of
Columbia, permitted these sales under a similar protoc
emergency contraception make 4 central arguments for changing
In the United States, emergency contraception is available
emergency contraception’s prescription status. These include the
without a prescription in California, Washington, Maine, New
demonstrated safety of emergency contraception; the need for
Mexico, Hawaii, and Alaska, under certain conditions.
equitable access to emergency contraception; the high societal
Alaska, Hawaii, Maine, and Washington allow pharmacists to
costs of unwanted pregnancy and prescription-only emergency
Nonprescription Availability of Emergency Contraception in the United States
contraception; and the absence of an increase in the incidence of
know the timeline for acceptable emergency contraception
pregnancy, unprotected sexual intercourse, or sexually
prescription; in 2001, 40% of practitioners in an American
transmitted diseases with emergency contraception usage.
health maintenance organization demonstrated similar
According to the FDA Durham-Humphrey Drug
knowledge deficiencies.Because of their religious beliefs or the
Amendment Act of 1951, all medications should be available
practice patterns or protocols at their health care institution,
over-the-counter unless they are ‘‘dangerous, addictive, or so
some health care providers may refuse or not be permitted to
complex to use that a learned intermediary is required.’’
prescribe emergency contraception, even for survivors of sexual
Grimes et Ellertson et al,and other advocates of over-the-
assault.Although Directive 36 of the US Catholic
counter emergency contraception argue that emergency
Bishops’ Ethical and Religious Directives for Catholic Healthcare
contraception meets none of the restrictions outlined in this
Services permits emergency contraception for female sexual
amendment and that the adverse effects of emergency
assault survivors who are not pregnant, a recent study indicated
contraception do not render it unsafe. As evidence supporting
that only 5% of Catholic hospital EDs prescribe emergency
their beliefs, they offer that (1) emergency contraception is
contraception on request, and only 23% provide it for sexual
nontoxic, has self-limited and generally mild adverse effects,
rarely induces serious adverse events, and is safer than many
Using a 1992-98 national database, Amey and Bishai
over-the-counter medications; (2) no deaths, suicides, or adverse
calculated that less than half of all women potentially eligible to
medical events have been reported from overdose with
receive emergency contraception after sexual assault were given
emergency contraception; (3) emergency contraception is not
it by their ED provider. Other reported access barriers include a
teratogenic, and it poses no danger to the woman or her fetus
woman’s lack of knowledge of emergency contraception and
if taken during pregnancy; (4) emergency contraception
lack of financial or other resources to obtain emergency
regimens are equally suited for all women, and the regimens
contraception.Foster et alreport that women might not
are simpler than over-the-counter medications for other
be prescribed emergency contraception because they are
purposes; (5) emergency contraception’s only indication is
unaware of its existence or how to obtain it.According to
unprotected intercourse and a desire to prevent pregnancy,
Free et even women educated about emergency
which can be recognized by the patient; (6) emergency
contraception may be embarrassed to ask a health care provider
contraception does not require professional monitoring; and
for it or have had negative experiences with providers in
(7) the dose for emergency contraception is fixed and does
attempting to obtain it. Other women may simply not be able
not need to be adjusted based on the medical needs of the
to afford prescribed emergency contraceptiondparticularly
given the additional costs of being treated by a clinician, living
Several authors report problems with access to prescription-
too far from a place that offers it, or obtaining their health care
only emergency contraception, even when it should ideally be
from places where it is unavailable.
available. For example, when researchers posing as women who
According to over-the-counter emergency contraception
experienced a condom breakage called physicians listed as
proponents, widespread over-the-counter emergency
emergency contraception providers on an emergency
contraception would overcome access difficulties by allowing
contraception Web site, only 76% of 200 calls successfully
patients to privately obtain emergency contraception whenever
resulted in appointments or telephone prescriptions for
they chose and at a lower cost.In support of this claim,
emergency contraception.Studies note that for places that
Killick and Irvingfound that a greater proportion of women
ordinarily offer emergency contraception, access to emergency
were able to take emergency contraception within 24 hours of
contraception is reduced on nights, weekends, and
unprotected intercourse when they were able to access
dwhen patients are more likely to need emergency
emergency contraception directly from a pharmacy without a
contracepdand that quick access to emergency
prescription. In focus groups of women in 4 European countries
contraception from emergency departments (EDs) is not always
that permit over-the-counter emergency contraception,
participants expressed satisfaction that over-the-counter
Health care provider knowledge deficienciesand
availability eliminated time and cost barriers.As far as the
religious beliefs about emergency contraception are other
knowledge barrier to access, some authors believe that
reported reasons for reduced access to prescription-based
emergency contraception would be better marketed by
emergency contraception. According to a 1990 study, one
pharmaceutical companies if it were available over-the-counter
quarter of general practitioners in the United Kingdom did not
and that such marketing campaigns would increase knowledge
*Directive 36 reads: ‘‘Compassionate and understanding care should be given to a person who is the victim of sexual assault. Healthcare providersshould cooperate with law enforcement officials, offer the person psychological and spiritual support and accurate medical information. A female whohas been raped should be able to defend herself against a potential conception from the sexual assault. If, after appropriate testing, there is noevidence that conception has occurred already, she may be treated with medications that would prevent ovulation, sperm capacitation, orfertilization. It is not permissible, however, to initiate or recommend treatments that have as their purpose or direct effect the removal, destruction,or interference with the implantation of a fertilized ovum.’’
Nonprescription Availability of Emergency Contraception in the United States
of emergency contraception’s existence and recommended
emergency contraception only through clinic visits. Women in
the advance provision group were more likely to use emergency
Over-the-counter emergency contraception proponents also
contraception than women in the other groups; however, the
argue that providing emergency contraception without a
incidence of pregnancy and sexually transmitted diseases and
prescription will reduce health care expenditures. Using a decision
condom use were similar among all 3 groups. Three other
model, Marciante et alcalculated the ‘‘physician cost’’ alone of
studies report that repeated use of emergency contraception is
prescribed emergency contraception using the Yuzpe method to
uncommon among women with advance provision of
be $67.26 for private payers and $36.60 for public payers. This
estimate does not account for facilities costs, laboratory costs, and
found that postpartum women in San Francisco who had
nursing costs. Marciante et estimated a cost savings of $48 and
advance provision of emergency contraception more than
$158 for public and private payers, respectively, if emergency
doubled their use of routine contraception to 80% during the
contraception were available directly from a pharmacist rather
than through a physician visit. They projected greater savings witha levonorgestrel-only based regimen. Trussell et almodeled the
expected cost savings from advance provision of emergency
contraception among women using barrier and behavioral
Apart from moral objections to emergency contraception
contraceptive methods. Compared to the costs of unintended
usage, most opponents of over-the-counter emergency
pregnancy, the projected cost savings through advance provision
contraception argue that concerns remain about over-the-
of emergency contraception (when emergency contraception is
counter emergency contraception’s adverse health effects and
prescribed before women need to use it) in a managed-care setting
potential misuse by girls and young adolescents, that over-
are $263 to $498 and in a public payer setting are $99 to $205.
the-counter emergency contraception will not create the social
These cost savings are based on the assumption that widespread
benefits proffered by the over-the-counter emergency
access to over-the-counter emergency contraception and resultant
contraception proponents, that it will decrease patient reliance
greater usage would result in fewer unplanned pregnan
on primary contraceptive measures, and that it will decrease
Trussell et alalso estimate that emergency contraception
opportunities for medical oversight of emergency contraception
could result in a greater than 50% reduction in abortion rates if
and counseling on safer sexual practices. Some particularly vocal
it were used in all cases of observable contraceptive failure or
opponents of over-the-counter emergency contraception include
unprotected intercourse. In a study that examined over-the-
Concerned Women for America, the Christian Medical
counter emergency contraception impact on abortion rates,
Association, the Family Research Council, the American
Wells et alpredicted that during the first 4 months of a
Association of Pro-Life Obstetricians and Gynecologists, and
Washington State over-the-counter emergency contraception
pilot program, 207 unintended pregnancies and 103
Over-the-counter emergency contraception opponents
unintended abortions were prevented. At the completion of the
mention concerns similar to those raised by acting FDA director
pilot program, Gardner et observed a 5% reduction in
Steven Galson about girls’ and young adolescents’ access to
abortions and a 7% reduction in teenage pregnancy rates in
over-the-counter emergency contracepOpponents
1998 but conceded that there was a similar decline nationwide
are concerned about the safety of emergency contraception in
for these characteristics. They concluded that a definitive
adolescents because they believe emergency contraception has not
statement on the effect of over-the-counter emergency
been adequately tested for its adverse effects on these patients.
contraception on unplanned pregnancy and abortion rates
They believe this concern is particularly relevant because
would require a longer observation period.
adolescents are likely to use over-the-counter emergency
Advocates of over-the-counter emergency contraception cite
contraception. This contention is supported by studies
several studies showing either no change or a decrease in the
reporting that the majority of users of emergency contraception
frequency of unprotected sexual intercourse and sexually
are younger than 25 years.Additionally, they contend that this
transmitted diseThey also note studies that show no
vulnerable group may use over-the-counter emergency
change or an increase in contraceptive use among older
contraception indiscriminately and without regard to primary
adolescents and women receiving emergency contraception
prevention of pregnancy or sexually transmitted diseases.
either directly from a pharmacist or through advance provision
Over-the-counter emergency contraception opponents further
of emergency contraception prescribed from a clinic. For
argue that the benefits of over-the-counter emergency
example, a recent single-blind, randomized, controlled trial in
contraception are not as significant as proponents say. There are a
California by Raine et compared use of emergency
few studies on the effects of advance provision and over-
contraception, incidence of pregnancy and sexually transmitted
the-counter emergency contraception to support this position.
diseases, and condom use over a 6-month period in 3 groups of
A 2000 study of advance emergency contraception provision to
women: one group received emergency contraception from a
low-income women at a Title X clinic shows lower use of
pharmacist without a prescription, one group was provided
emergency contraception than anticipated,which suggests
emergency contraception in advance, and one group received
that emergency contraception may not have as much of an
Nonprescription Availability of Emergency Contraception in the United States
Table. ED studies of emergency contraception.
20% Of 204 female sexual assault patients received EC
5% Provided EC on request; 23% provided EC to rape victims;
55% of EDs would not dispense EC under any circumstances
79.5% Of EC requests were due to condom breakage;
frequency of EC requests was highest on weekends
96% Of EDs received EC requests; 57% provided EC; 56%
thought EDs should provide EC; 62% of respondentsopposed OTC EC.
Survey of 12 Catholic-run EDs in southern
8 Forbade physicians to prescribe EC after sexual assault
Survey of reproductive health care, family
78% Of ED doctors had prescribed EC, generally to sexual
assault victims, an average of 5.8 times per year
Descriptive study of visits to a rural Welsh
Comparison of visits by general practice registration
Retrospective review of ED NPs’ prescription
100% Of NP-administered EC was given within 72 hours; 95%
was given after negative pregnancy test; 71% was given after
documentation of other medications or medical conditions
The total EC requests decreased from 196 to 164; however,
the number of requests by teens increased from 63 to 74;63% of requests occurred outside local pharmacy hours.
Of 69 responding departments, all were aware of EC; 83%
prescribed ED; 56% prescribed EC appropriately; antiemeticswere routinely prescribed by 78.9%
Of 102 responding departments, 38% of respondents never
prescribe EC; 10% always prescribe EC; 44% prescribe only ifthe patient cannot consult a GP within 72 hours; and 8%have no fixed practice
47% Of non-Catholic EDs vs 6% of Catholic EDs offered routine
EC counseling for sexual assault victims; 57% of non-Catholic EDs vs 41% of Catholic EDs had EC on site
Total EC dispensation increased 8-fold; 81% was
nonprescription EC direct from the hospital pharmacy
21% Of 94 eligible sexual assault patients received EC
20% Of Catholic hospitals prohibit prescription of EC, including
without ‘‘conscience clause’’ laws
EC for rape victims; individual physicians varied in theirrespect of these restrictions; no difference was observed inEDs from states with and without conscience clauses
Knowledge/opinion studiesAbbott et al (2004)
77% Of women surveyed had heard of EC; of those who knew
20% More providers prescribed EC at least once a year;
knowledge of proper EC use and indications was greatly
Study participants described conflicting attitudes about ease of
obtaining EC and their views on adolescent EC requests
88% Were willing to give EC to victims of sexual assault; this
percentage was higher if the assailant was likely to be HIV-infected but lower if the patient had had consensual sex
NY ED practitioners were more willing than other US ED
practitioners to offer EC after sexual assault and afterconsensual sexual exposures
CFFC, Catholics for a Free Choice; EC, emergency contraception; OTC, over the counter; NP, nurse practitioner; GP, general practitioner.
Nonprescription Availability of Emergency Contraception in the United States
impact on unplanned pregnancies for this group. A major
emergency contraception, and lack of knowledge or negative opinions
prospective study of free, advance provision of emergency
about emergency contraception by patients or ED providers.
contraception to all women in a community in Scotland showed
Of particular relevance to the over-the-counter emergency
no significant decrease in abortion rates among that community
contraception controversy, studies from the United Kingdom by
compared with other Scottish regions.An article from Sweden
Kerins et and Mawhinney and Dornanexamined
found no decrease in the abortion rate since emergency
emergency contraception use in EDs 1 year before and 1 year
contraception became available over-the-counter, but the authors
after emergency contraception became available without a
believed that this finding was due to lack of widespread use of
prescription in the United Kingdom. Although the studies
emergency contraception.Furthermore, in the
involve only 3 EDs, both studies observed a decrease in
aforementioned article by Raine et there was no decrease in
emergency contraception requests after emergency contraception
the incidence of pregnancy and sexually transmitted diseases
was available over-the-counter. The Mawhinney and Dorna
among women with advance provision of emergency
study noted that there was a relative increase in requests for
emergency contraception by teenagers and that most emergency
Some over-the-counter emergency contraception opponents
contraception requests occurred after local pharmacies were
argue that emergency contraception usage without a clinician’s
closeIn addition, a Minnesota hospital instituted a
oversight will increase women’s engagement in risky sexual
simulated over-the-counter emergency contraception program in
practicesor result in emergency contraception being used as
which they permitted direct emergency contraception provision
regular contraception.In addition, some opponents are
from the hospital pharmacy, without a physician prescription,
worried that if emergency contraception were available over-the-
through a standing order from hospital physicians.The
counter, then the opportunity for medical oversight and
study did not report the impact of emergency
counseling that accompanies prescription writing would
contraception on the ED directly but did comment that 81%
disappear. Over-the-counter emergency contraception
of all emergency contraception provided by the hospital
opponents especially fear the loss of the chance to examine
after institution of the protocol was directly from the pharmacy.
patients for the presence of sexually transmitted diseases, detect
Apart from the apparent reduction in ED visits for emergency
medical contraindications to emergency contraception, and
contraception noted in these studies, over-the-counter
screen for sexual abuse, assault, and domestic violence or other
emergency contraception could affect emergency medicine
health-related They also suggest that the absence of
practice in the United States in a number of positive ways. It could
counseling would lead to inappropriate, incorrect, and repeated
also result in a reduction in ED health care expenditures for
usage, particularly among adolescents and women with low levels
emergency contraception (eg, less money spent on medications),
of education. A few studies substantiate this worry. In the Endres
the creation of a safety mechanism for emergency contraception
et al2000 study of women presenting to an inner-city family
provision (ie, patients could obtain emergency contraception
planning clinic, only 18% of those given advance provision of
elsewhere if they were not provided with it in the ED), and the
emergency contraception used it correctly. According to Jackson
removal of the ED from legal controversies on emergency
et al,in a study comparing emergency contraception
contraception provision. These potential benefits might be
knowledge and behavior in low-income, postpartum women
accompanied by adverse costs to patients, however. For example,
given advance provision of emergency contraception versus
although there are no studies examining this issue in the ED
placebo, only 25% of study participants who received advance-
setting, over-the-counter emergency contraception might
provision emergency contraception knew the correct timing for
discourage patients who need medical evaluations or treatments
emergency contraception use at the end of the study period.
from receiving them. Until these potential impacts areunderstood, ACEP joins with other health professional
organizations in supporting efforts for the nonprescription
availability of emergency contraception. Future studies
examining the impact of over-the-counter emergency
The summarizes studies of emergency contraception in
contraception should be helpful in further guiding emergency
EDs.This list of studies was obtained by a
medicine practice on this important subject.
MEDLINE search using the terms ‘‘emergency contraception,’’‘‘post-coital contraception,’’ ‘‘morning-after pill’’ and ‘‘accident
Supervising editor: Debra E. Houry, MD, MPH
and emergency department,’’ ‘‘emergency department,’’‘‘emergency room,’’ ‘‘casualty department,’’ and by hand search
Funding and support: Dr. Merchant is supported by a Career
of references from relevant journal articles. Sixteen studies
Development grant from the National Institute for Allergy and
concern emergency contraception use in the ED, and 5 examine
Infectious Diseases, National Institutes of Health, K23
patient or provider knowledge or opinions on emergency
contraception. As noted previously, some studies show lack of
Publication dates: Received for publication May 9, 2005.
emergency contraception usage after sexual assault, comparatively
Revision received June 21, 2005. Accepted for publication
less usage at Catholic hospitals, variations in practice patterns for
July 1, 2005. Available online September 13, 2005.
Nonprescription Availability of Emergency Contraception in the United States
Reprints not available from the authors.
17. Ho PC, Kwan MS. A prospective randomized comparison of
levonorgestrel with the Yuzpe regimen in post-coital contraception.
Address for correspondence: Roland C. Merchant, MD, MPH,
Department of Emergency Medicine, Rhode Island Hospital, 593
18. Task Force on Postovulatory Methods of Fertility Regulation.
Eddy Street, Potter 228, Providence, RI 02903; 401-444-5109,
Randomised controlled trial of levonorgestrel versus the Yuzpe
regimen of combined oral contraceptives for emergencycontraception. Lancet. 1998;352:428-433.
19. Cheng L, Gulmezoglu AM, Oel CJ, et al. Interventions for
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Delegates approves a policy asking the FDA to OK increased
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‘Snake Oil Medicine: where every-one gets some echinacea’ Abridged from a talk to the Auckland Medical Society in December 2005 By Professor David Cole Early in 2005 Prof Kaye Ibbertson, the relentless grand vizier of the Marion Davis library and museum, asked me offer the Medical Historical Society some comments about the history of unorthodox medicine. I felt that, taking into accou